Venous thromboembolism management: where do novel anticoagulants fit?

Submassive Pulmonary Embolism: A Re-evaluation of Hemodynamic Instability

Current medical management of pulmonary embolism (PE) is driven by risk stratification, with thrombolytic treatment reserved for patients with hemodynamic instability. We describe a case of a man with acute submassive bilateral pulmonary emboli and a right popliteal deep vein thrombosis (DVT), who had persistent shortness of breath, tachycardia, and hypoxemia but remained normotensive and was therefore not treated with thrombolytics until he suffered a fatal cardiac arrest on hospital day six. We examine the indications, risks, and potential benefits of thrombolytic treatment in patients with submassive PE who exhibit signs of instability but do not meet current indications for thrombolytic treatment with persistent hypotension or shock.

A dabigatran etexilate phospholipid complex nanoemulsion system for further oral bioavailability by reducing drug-leakage in the gastrointestinal tract

Dabigatran etexilate (DE) is insoluble at neutral pH values but soluble at low pH values due to protonation, which is the major cause for the poor bioavailability of commercial DE products. Here, we first developed a DE nanoemulsion system and improved dissolution in simulated intestinal fluids by encapsulating DE into an oil phase, but 35.8% of the drug still leaked out. Further, we prepared a DE-phospholipid complex (DE-PC) to enhance lipophilicity and solubility of DE. The resulting DE-PC nanoemulsions significantly (P<0.05) reduced drug leakage and subsequent precipitation. As a result, the relative bioavailability of DE-PC nanoemulsions increased to 147.3% and 606.6% compared to DE nanoemulsions and commercial DE products, respectively. Thus, the presently developed drug-phospholipid complex nanoemulsion system is a promising drug delivery system for improving the oral bioavailability of pH-dependent soluble drugs.

Perioperative management of oral anticoagulants: a focus on target-specific oral anticoagulants

Although warfarin has historically been the dominant oral anticoagulant, newer target-specific oral anticoagulants (TSOACs) have been introduced in the marketplace in the past few years. Dabigatran, rivaroxaban, and apixaban, collectively referred to as TSOACs, have undergone extensive testing in comparison with warfarin and other anticoagulants for a variety of conditions. Compared with warfarin, the shorter time to peak effect, shorter half-life, and fewer drug-drug interactions have helped make the TSOACs attractive alternatives to warfarin for the prevention and treatment of thromboembolic disease associated with orthopedic surgery and atrial fibrillation as well as for the treatment of venous thromboembolism. However, their unique properties pose a challenge for their management in the perioperative period. This article reviews the current guideline-based approach to perioperative management of anticoagulants, the clinical data, and the recommendations supporting use of the TSOACs in the perioperative period. The article also addresses common pitfalls in their perioperative management. By understanding a few key properties of the new oral anticoagulants and with careful perioperative planning, physicians can ensure that their patients will safely undergo most surgical procedures with minimal disruption of their chronic anticoagulation.

Treatment and long-term management of venous thromboembolism

Venous thromboembolism covers a range of conditions from deep vein thrombosis to pulmonary embolism. Treatment aims to alleviate symptoms, minimize acute morbidity and mortality by preventing the extension or potentially fatal embolization of the initial thrombus, and avoid postthrombotic syndrome. Anticoagulant therapy is the mainstay of treatment, but treatment decisions and the choice of an appropriate anticoagulation agent are modified according to the predisposition for venous thromboembolism, the site and extent of thrombus, the presence or absence of symptomatic embolism, and patient's bleeding risk. Newer oral anticoagulants have been developed to overcome the drawbacks of other agents, improve patient care, and simplify and improve management.